InterRAI Child and Youth Mental Health-Screener (ChYMH-S): A Psychometric Evaluation and Validation Study

The Coronavirus Pandemic and Mental Health Presentations of Young Children

Children under the age of four are emotionally vulnerable to global disasters, such as the COVID-19 pandemic given the lack of socialization opportunities and coping mechanisms, and susceptibility to heightened caregiver stress. Currently, the extent to which the pandemic impacted the mental health of clinically referred young children is unknown. To evaluate how children's mental health outcomes were impacted during the pandemic, interRAI Early Years assessments (N = 1343) were obtained from 11 agencies across the Province of Ontario, during pre-pandemic and pandemic timepoints. Findings demonstrated that the number of completed assessments declined during the pandemic. Further, children's emotional concerns differed before and during the pandemic, whereby children exhibited greater emotional dysregulation during the pandemic. However, there were no significant differences when examining caregiver distress, parenting strengths, child distractibility/inattention or behavioural issues. Implications for young children and their families, clinicians, and policy makers are discussed.

A cross-sectional examination of service complexity in youths with co-occurring autism spectrum disorder and psychiatric or medical diagnoses across service sectors

Introduction

Autism spectrum disorder (ASD) is a heterogeneous, life-long, and complex condition. Youth diagnosed with ASD require several supports addressing core symptoms associated with the disorder, but also those resulting from co-occurring mental and physical health conditions. As a result, their care is overseen by numerous professionals spanning various service sectors, but communication between sectors is hindered due to the absence of a standardized assessment system to identify and triage youth to services. A paucity of information surrounding this population's service use lingers and a siloed delivery system persists.

Methods

Using archival data collected from 1,020 youth between 12 and 18 years of age, this study explored service complexity among autistic youth with and without psychiatric and medical co-occurring conditions in Ontario, Canada. In doing so, a negative binomial regression was utilized to investigate which predisposing, enabling, and need variables were associated with service complexity.

Results

Results revealed that experiencing financial difficulties was not associated with service complexity. However, age, sex, caregiver distress, comorbidity, intellectual disability, and evaluated health status were significant predictors. More specifically, female youth and youth with distressed caregivers had greater mental health service complexity scores. Additionally, youth diagnosed with two or more conditions in addition to ASD who required longer durations of programming, controlling for other predictors, had greater mental health service complexity scores. Yet, youth with an intellectual disability had lower service complexity scores.

Discussion

Clinical implications of this study are discussed to inform future investments into mental health efforts for autistic youth.

Age, Sex and Relationship Strengths: Internalizing Symptom Differences in Children and Youth Within a Clinical Sample

BACKGROUND

Internalizing problems such as depression, anxiety and anhedonia are particularly problematic due to their covert nature. Due to their deleterious effects on psychological well-being, social connection and education, it is important to understand the development of internalizing problems and their unique contributors.

OBJECTIVES

Examine whether internalizing symptoms vary by (i) age, and (ii) sex, and whether (iii) relationship strengths are associated with sex and internalizing symptoms.

METHOD

Using a polynomial model with Tweedie distribution with log link, this study examined relationships for 18,701 clinically referred children and adolescents between 4 and 18 years of age assessed using the interRAI Child and Youth Mental Health assessment.

RESULTS

Internalizing symptoms reported by children and adolescents varied by age and sex. Sex differences in internalizing symptoms became prominent after about six years of age with female adolescents reporting higher levels when compared to male peers. An increase in relationship strengths corresponded with a decrease in internalizing symptoms for both sexes. However, the pattern depended on sex. In our sample, females required a greater number of relationship strengths to observe a decrease in internalizing symptoms.

CONCLUSIONS

The current study illustrates a difference in internalizing symptoms between females and males with respect to age and relationship strengths. The results may have implications for prevention and intervention strategies geared towards internalizing symptoms for children and adolescents.

Mental Health Service Urgency in Children's Mental Health: Factors Impacting the Need for Expedited Services

Delayed access to mental health services for children and adolescents has been linked to an increased risk of harm and nonattendance to scheduled appointments. While studies suggest that the lack of standardized assessments for prioritizing individuals has contributed to long wait times, the inconsistent use of assessments across service sectors in Ontario continues to persist. This has contributed to a paucity of information surrounding which children and adolescents may require urgent mental health services. Using a large secondary data set, this study examined whether service sector (e.g., school), and other individual client characteristics (e.g., age, sex, legal guardianship, interpersonal and school conflict) predicted greater mental health service urgency in 61,448 children and adolescents assessed using the interRAI Child and Youth Mental Health Screener. Binary logistic regression revealed that all predictors, except for sector, showed a significant effect on service urgency. Findings are instrumental in prioritization, reducing the likelihood that children with acute needs remain on waitlists.

The interRAI Child and Youth Suite of Mental Health Assessment Instruments: An Integrated Approach to Mental Health Service Delivery

Various biological, social, psychological, and environmental factors impact children and youth living with mental health problems across their lifespan. To meet the wide-ranging challenges of mental illness, service system integration is needed to improve efficiencies and reduce fragmentation. Unfortunately, the mental health system has been plagued by the lack of coordination across services. There is a general consensus that mental health service delivery must ensure a child or youth's needs are addressed in a collaborative, coordinated, and seamless manner. A key element to successful integration is the development of a comprehensive standardized screening and assessment system. Numerous assessments have been developed to assess child mental health and functioning, but they typically have a very narrow focus with limited use and utility. Not only does this reduce the ability to take a life course perspective to mental health, but this uncoordinated approach also results in redundancies in information collected, additional resources, and increased assessor burden for children, youth, and their families. The interRAI child and youth mental health assessment suite was developed in response to the need for an integrated mental health system for young persons. This suite includes screening and assessment instruments for in-patient and community settings, emergency departments, educational settings, and youth justice custodial facilities. The instruments form a mental health information system intentionally designed to work in an integrated fashion beginning in infancy, and incorporate key applications such as care planning, outcome measurement, resource allocation, and quality improvement. The design of these assessment tools and their psychometric properties are reviewed. Data is then presented using examples related to interpersonal trauma, illustrating the use and utility of the integrated suite, along with the various applications of these assessment systems.

Examining the role of neuropsychology in community-based pediatric mental health care

Numerous investigations have demonstrated a link between neuropsychological functioning and mental health. Children with a history of neurological compromise are more vulnerable to mental illness and there is a growing literature indicating that neurocognitive functioning predicts psychosocial outcomes in adulthood. However, not much is known about how neuropsychological information is utilized in community-based mental health care. Thus, we examined what neuropsychological information is available to pediatric centers and how neuropsychological functioning relates to treatment outcomes in these settings. Two content analyses were conducted to identify mental health indicators across different intake sources and these results were compared to a structured intake. Further, a series of standardized neurocognitive and neuroemotional measures were completed and these indices were correlated with treatment outcomes. Qualitative results confirmed that neuropsychological factors are often overlooked when utilizing current approaches and that observable symptoms are a primary focus of treatment. Additionally, neurocognitive deficits were associated with self-reported interpersonal difficulties and caregivers' reports of externalizing; however, only caregiver-reported externalizing challenges correlated with treatment outcomes. Importantly, neurocognitive challenges were associated with long-term treatment responses, suggesting that these factors may be an important therapeutic target. Collectively, these findings indicate a need to incorporate neuropsychological factors in pediatric mental health treatment.

Substance Use among Youth in Community and Residential Mental Health Care Facilities in Ontario, Canada

There is a need to improve the integration of substance use and mental health care for children and youth. This study examines risk and protective factors for substance use among youth with mental health conditions who received community-based or residential care services between 2012–2020 in Ontario, Canada. In this study, a cross-sectional design was used to examine patterns and factors associated with substance use among youth (12–18 years) assessed in the community (n = 47,418) and residential (n = 700) mental health care facilities in Ontario, Canada. Youth were assessed with the interRAI Child and Youth Mental Health Assessment (ChYMH). Substance use is identified by any substance use (including alcohol) 14 to 30 days prior to assessment. Logistic regression with generalized estimating equations was used to examine clinical, psychosocial, and environmental factors associated with substance use. This study shows that 22.3% of youth reported the use of substances in the community settings and 37% in residential settings. Older age group (Youth older than 16 years), being a victim of abuse, having experienced self-injurious ideation/attempt, being at risk of disrupted education, and having a parent/caregiver with addiction or substance use disorder were significantly associated with substance use. Several factors reduced the risk of substance use, including being a female, having anxiety symptoms, and having cognition problems. In conclusion, the study found that individual and parental factors increase youth’s risk of substance use, highlighting the importance of a holistic approach that includes consideration of social and biological risk factors to prevention/risk reduction, risk assessment, management, and recovery.

Risk of Injury to Others: The Development of an Algorithm to Identify Children and Youth at High-Risk of Aggressive Behaviours

Youth violence is considered one of the most preventable causes of morbidity and premature mortality. Various risk factors have previously been identified, however, there is presently a crucial need to develop effective decision-support tools in order to identify children and youth at increased risk for violence. The current study utilised data collected from the interRAI Child and Youth Mental Health Screener (ChYMH-S), within the province of Ontario, to develop and validate a methodology for the purpose of identifying young persons who were at greater risk of harm to others. Additional data from 59 mental health agencies validated the algorithm, and it was found to be a strong predictor of harmful behaviour toward others. The RIO algorithm provides a valuable decision-support tool with strong psychometric properties that may be used to identify young persons who exhibit signs or symptoms associated with increased likelihood of harm toward others, in order to provide early intervention efforts for these vulnerable youth, thereby reducing the likelihood of future aggressive behaviours.

Mood Disturbances Across the Continuum of Care Based on Self-Report and Clinician Rated Measures in the interRAI Suite of Assessment Instruments

BACKGROUND

Mood disturbance is a pervasive problem affecting persons of all ages in the general population and the subset of those receiving services from different health care providers. interRAI assessment instruments comprise an integrated health information system providing a common approach to comprehensive assessment of the strengths, preferences and needs of persons with complex needs across the continuum of care.

OBJECTIVE

Our objective was to create new mood scales for use with the full suite of interRAI assessments including a composite version with both clinician-rated and self-reported items as well as a self-report only version.

METHODS

We completed a cross-sectional analysis of 511,641 interRAI assessments of Canadian adults aged 18+ in community mental health, home care, community support services, nursing homes, palliative care, acute hospital, and general population surveys to develop, test, and refine new measures of mood disturbance that combined clinician and self-rated items. We examined validity and internal consistency across diverse care settings and populations.

RESULTS

The composite scale combining both clinician and self-report ratings and the self-report only variant showed different distributions across populations and settings with most severe signs of disturbed mood in community mental health settings and lowest severity in the general population prior to the COVID-19 pandemic. The self-report and composite measures were strongly correlated with each other but differed most in populations with high rates of missing values for self-report due to cognitive impairment (e.g., nursing homes). Evidence of reliability was strong across care settings, as was convergent validity with respect to depression/mood disorder diagnoses, sleep disturbance, and self-harm indicators. In a general population survey, the correlation of the self-reported mood scale with Kessler-10 was 0.73.

CONCLUSIONS

The new interRAI mood scales provide reliable and valid mental health measures that can be applied across diverse populations and care settings. Incorporating a person-centered approach to assessment, the composite scale considers the person's perspective and clinician views to provide a sensitive and robust measure that considers mood disturbances related to dysphoria, anxiety, and anhedonia.

School Disengagement and Mental Health Service Intensity Need Among Clinically Referred Students Utilizing the interRAI Child and Youth Mental Health Assessment Instrument

Although mental health challenges are widespread, impacting 1 in 5 children and youth, only 25% of these young people receive the required mental health supports. Unmet mental health needs are strongly associated with functional impairments including poor self-care, interpersonal challenges, and school difficulties among young people. School disengagement, or a student's lack of involvement in education through interest, curiosity, motivation, and active participation, is associated with a wide array of detrimental outcomes including chronic mental health difficulties, conduct and delinquent behaviors, criminal justice involvement, and unemployment in adolescence and adulthood. Disengagement observed within the school setting may be indicative of underlying mental health challenges and reflective of service intensity need. The current study extends the literature by examining the relationship between school disengagement and mental health service intensity need among 14,750 clinically referred students across elementary and secondary school utilizing the interRAI Child and Youth Mental Health instrument. Findings indicated that more than 25% of clinically referred students were at heighted risk for school disengagement and required high-intensity services. Further, mental health service intensity need was positively associated with risk of school disengagement among students, along with the specific reason for referral (i.e., psychiatric symptoms, harm to self, harm to others, or addiction or dependency), after controlling for sex and age. Implications of the findings are explored within the context of the school setting and future directions are suggested.

Examining the Mental Health Presentations of Treatment-Seeking Transgender and Gender Nonconforming (TGNC) Youth

Recent research suggests that transgender and/or gender nonconforming (TGNC) youth present with heightened levels of mental health problems compared to peers. This study seeks to examine the mental health needs of a large sample of treatment-seeking TGNC youth by comparing them to cisgender males and females. Participants were 94,804 children and youth ages 4-18 years (M = 12.1, SD = 3.72) who completed the interRAI Child and Youth Mental Health Instrument (ChYMH) or Screener (ChYMH-S) at participating mental health agencies in the Ontario, Canada. Overall, the mental health presentations of TGNC youth were similar to cisgender females but at higher acuity levels. TGNC youth showed significantly higher levels of anxiety, depression, social disengagement, positive symptoms, risk of suicide/self-harm, and were more likely to report experiencing emotional abuse, past suicide attempts, and a less strong, supportive family relationship than cisgender females and males. Clinical implications of these findings are discussed.

Following the Epidemic Waves: Child and Youth Mental Health Assessments in Ontario Through Multiple Pandemic Waves

Emerging studies across the globe are reporting the impact of COVID-19 and its related virus containment measures, such as school closures and social distancing, on the mental health presentations and service utilization of children and youth during the early stages of lockdowns in their respective countries. However, there remains a need for studies which examine the impact of COVID-19 on children and youth's mental health needs and service utilization across multiple waves of the pandemic. The present study used data from 35,162 interRAI Child and Youth Mental Health (ChYMH) assessments across 53 participating mental health agencies in Ontario, Canada, to assess the mental health presentations and referral trends of children and youth across the first two waves of the COVID-19 pandemic in the province. Wave 1 consisted of data from March to June 2020, with Wave 2 consisting of data from September 2020 to January 2021. Data from each wave were compared to each other and to the equivalent period one year prior. While assessment volumes declined during both pandemic waves, during the second wave, child and youth assessments in low-income neighborhoods declined more than those within high-income neighborhoods. There were changes in family stressors noted in both waves. Notably, the proportion of children exposed to domestic violence and recent parental stressors increased in both waves of the pandemic, whereas there were decreases noted in the proportion of parents expressing feelings of distress, anger, or depression and reporting recent family involvement with child protection services. When comparing the two waves, while depressive symptoms and recent self-injurious attempts were more prevalent in the second wave of the pandemic when compared to the first, a decrease was noted in the prevalence of disruptive/aggressive behaviors and risk of injury to others from Wave 1 to Wave 2. These findings highlight the multifaceted impact of multiple pandemic waves on children and youth's mental health needs and underscore the need for future research into factors impacting children and youth's access to mental health agencies during this time.

Abuse, Mental State, and Health Factors Pre and during the COVID-19 Pandemic: A Comparison among Clinically Referred Adolescents in Ontario, Canada

Throughout the COVID-19 pandemic, population surveys revealed increased levels of anxiety and depression, while findings from large-scale population data analyses have revealed mixed findings with respect to the mental health consequences for children and youth. The purpose of this study was to examine the impact of the COVID-19 pandemic on the well-being and health-compromising behaviors of adolescents (12-18 years) previously referred for mental health services. Data were collected (pre-pandemic n = 3712; pandemic n = 3197) from mental health agencies across Ontario, Canada using the interRAI Child and Youth Mental Health assessment. Our findings revealed no increased incidence of witnessing domestic violence nor experiencing physical, sexual, or emotional abuse. Further, there were no increases in the risk of self-harm and suicide, anxiety, or depression among our sample of clinically referred youth. Finally, results demonstrated no increase in problematic videogaming/internet use, disordered eating, or alcohol intoxication, and a decrease in cannabis use. Our findings add to the growing body of knowledge as to the impact of the COVID-19 pandemic on children and youth. Further, findings underscore the importance of understanding the nuanced impact of the pandemic on various subgroups of children, youth, and families and highlight the need for continued monitoring of outcomes for these children and youth.

Traumatic life events, polyvictimization, and externalizing symptoms in children with IDD and mental health problems

BACKGROUND AND AIMS

This study aims to examine the rates of potentially traumatic events (PTEs) and polyvictimization, as well as interrelationships among PTE types in children and youth with intellectual developmental disorder (IDD) and co-occurring mental health issues. It also examines the association between polyvictimization (experiencing three or more PTEs) and externalizing symptoms, controlling for IDD severity, sex and age.

METHOD

The study utilized archival data collected from 2012 to 2020 by trained assessors (e.g., nurses, social workers, psychologists) at intake into clinical mental health services in the Province of Ontario, Canada. The sample included 502 children and youth (age range: 4-18 years) who were assessed using the interRAI Child and Youth Mental Health and Developmental Disability (ChYMH-DD) instrument. Using this standardized assessment, trained clinicians reported on children's demographics, traumatic life events, and externalizing symptoms (proactive and reactive aggression) among other physical and mental health indicators.

RESULTS

64.74 % of the children had experienced at least one type of PTE, whereas 33.06 % experienced lifetime polyvictimization. Most of the PTE types were positively correlated, with the strongest associations between physical, emotional abuse, witnessing domestic violence, and parental addiction. In a multivariate model, experiences of three or more PTEs (vs. none), mild or moderate IDD (vs. severe/profound), male sex (vs. female) were associated with greater externalizing symptoms. There was a quadratic relationship between age and externalizing symptoms.

CONCLUSION

The project advances knowledge on trauma and polyvictimization patterns and their association with IDD severity and externalizing symptoms in this population. Trauma-informed services should be tailored to the specific needs of these children.

Suicidality in 12-Year-Olds: The Interaction Between Social Connectedness and Mental Health

Suicidal thoughts and behaviors (STB) are a leading cause of death in adolescence. To date, most research with youth has focused on risk factors for suicide; and less attention has been paid to resilience factors. This study examined whether positive beliefs and social connectedness moderate associations between mental health symptoms and STB. A community sample of 12-year-olds (N = 60) completed self-report questionnaires on their STB, mental health symptoms, positive beliefs and social connectedness. Nearly 20% of the adolescents reported STB. STB was associated with increased mental health symptoms and lower scores on the resilience measures. A significant moderating effect of social connectedness showed that youth with a combination of poor mental health and high levels of social support exhibited lower levels of STB. There was no significant moderating effect of positive beliefs. These results indicate that social support should be screened for in primary care and incorporated into youth suicide prevention programs.

Interpersonal polyvictimization: Addressing the care planning needs of traumatized children and youth

BACKGROUND

Exposure to maltreatment has a detrimental impact on both physical and mental health. However, research on the relationship between polyvictimization and care planning needs is scarce.

OBJECTIVES

This study investigated the associations between interpersonal polyvictimization and care planning needs for children and youth, controlling for sex and age differences.

PARTICIPANTS AND SETTINGS

The sample included 18,701 children and youth (M_age = 12.33, SD_age = 3.53) between 4 and 18 years. Participants were recruited from over 58 mental health agencies, facilities, and schools in Ontario, Canada between November 2012 and February 2020.

METHODS

Multivariate binary logistic regression was used to investigate polyvictimization, sex and age groups, as predictors on care planning outcomes. Significant interaction effects were further examined using simple effects analyses.

RESULTS

Children and youth experiencing polyvictimization, compared to those who did not, were more likely to report attachment difficulties, lack of informal support, interpersonal conflict, substance use and harm to self or others. In addition, the relationship between polyvictimization and attachment and interpersonal conflict care planning was moderated by sex.

CONCLUSIONS

Findings emphasize the importance of focusing on interpersonal polyvictimization and sex differences when developing treatment plans for a variety of care planning needs. Mental health practitioners could utilize the study findings to guide their clinical practices and ensure effective services are provided to those seeking mental health care.

An Examination of Correlates of Quality of Life in Children and Youth With Mental Health Issues

Quality of life (QoL) is significantly lower in children with mental health issues compared to those who are typically developing or have physical health problems. However, little research has examined factors associated with QoL in this particularly vulnerable population. To address this limitation, 347 clinically referred children and adolescents were assessed using the interRAI Child and Youth Mental Health (ChYMH) Assessment and Self-reported Quality of Life- Child and Youth Mental Health (QoL-ChYMH). Hierarchical multiple linear regression analyses were conducted to examine QoL at the domain-specific level. Children and adolescents who experienced heightened anhedonia and depressive symptoms reported lower social QoL (e.g., family, friends and activities; p = 0.024, 0.046, respectively). Additionally, children and youth who experienced heightened depressive symptoms reported lower QoL at the individual level (e.g., autonomy, health; p = 0.000), and level of basic needs (e.g., food, safety; p = 0.013). In contrast, no mental state indicators were associated with QoL related to services (e.g., school, treatment). Due to the paucity of research examining predictors of QoL in children and youth with mental health challenges, this study contributes to the field in assisting service providers with care planning and further providing implications for practice.